We're Not Providers for Consumers/Clients

The following was originally posted to the HCPLive network blog Psychiatry Talk.

Recently Paul Krugman wrote an interesting piece in the NY Times titled "Patients Are Not Consumers." In it, he wonders what has gone wrong with us if receiving health care is like buying a car?

While he did not discuss specifically the treatment of mental illness and psychotherapy, those of us in this field have similar concerns.

Thinking about this article sent me to the dictionary (Webster’s Unabridged 20^th Century-2nd Edition) to look up a couple of words that are used in this debate.

— A person who uses goods or services to satisfy his need rather than to resell them or produce other goods with them.

Client— A dependent one under protection or patronage of another person or company in its relationship to a lawyer, accountant etc, engaged to act on its behalf, loosely, a customer.

Patient— A person receiving care or treatment; especially, a person under the care of a doctor; as the physician visits his patient morning and evening.

It is wonderful to observe how inapprehensive those patients are of their disease- Blackmore

Provider— One who provides, furnishes or supplies; one who procures what is wanted

Care giver— (There is no single word as such)

Rather than further try to analyze or argue why and how these words should be used, I would like to present a few real situations and ask you to consider which words seem most appropriate :

1-Mrs. Jones as you know I check blood levels of Lithium and do other routine blood tests on my (choose one — patients, clients , or consumers) and I have just received the results back. While the lithium level is right where we want it, I do note that your TSH is high which indicates that you may have a hypothyroid condition which could be contributing to your recent depressive symptoms. I would like to call your (choose one — primary care provider, medical care giver, health care provider, primary care physician) and I would like you to make an appointment with her.

2-(Phone call) Is this the emergency room (choose one — provider, care giver, physician)? My (choose one- consumer, client, patient) has just informed me that she took an overdose of tranquilizers and antidepressants which I have been prescribing for her and I have arranged for an ambulance to bring her to the hospital.

3-It appears that you are jealous of the other (choose one — consumers, clients, patients) in the waiting room as you were jealous of your siblings and you want to leave me as you left your other (choose one : providers, caregivers, therapists)

I understand that some of the words with which many of us are uncomfortable have come from the people who are trying to develop healthcare systems for large numbers of people. For them, such words as providers, caregivers, consumers or clients may better suit the concepts which they are dealing with in the abstract. One might argue that the meaning of words may change but if one is clear in regard to their own identity, perhaps it isn’t a big deal if a different word is used. If I have established a doctor-patient relationship with a patient and I am clear as to my code of ethics why should I get upset if a patient or an insurance company calls me a provider ? The problem is that there is a blurring of the expectations between a casual sale of an automobile to a consumer and the expectation of a physician or other health care professional who is entrusted with the care of a patient.

There is a special bond that physicians have with patients which has its origin with the Hippocratic Oath. It has come to mean a selfless dedication to doing everything in one’s power to help the person who has trusted us with their healthcare. There may be obstacles and complications related to third party payers, treatment being shared by multiple specialties and disciplines, patients being guided by information from the Internet etc, but we still view the patient as someone we owe a special obligation to do our absolute best to assist. The objective and subjective meaning of the words provider, client, consumer, etc. do not convey the relationship which we feel towards our patients and which they usually feel towards us . In the past many of our non-physician colleagues in the mental health profession also used this model and have a similar bond with their patients.

My generation of psychiatrists and other mental health professionals, I believe are clear in our role and the expectations of our patients. However, it is somewhat more confusing for young people just out of training especially when they take positions in Mental Health Clinics where the newer terminology may be used. It may be easier for a young psychiatrist who has had some experience in medical school and during internship (PGY 1 year) where he or she has functioned in life and death situations.

Those experiences become the underpinning of how they will view the people that they will treat. Certainly that can become eroded if they are in an environment where other models are used. I also believe that it may be more difficult for young social workers and psychologists to appreciate the differences if they have only worked with these new terms during their training.

In ten years from now will this be a moot question? Or will our attention to this debate now and the public’s desire for special relationships with the people who provide their health care treatment (physical and mental ) prevail in reality and in the terminology which we use?

I would welcome comment from anyone on this topic. I also am especially interested in the experience of our international readers of this blog (who make up about 50 % of the visitors to this site) Are there new words in other languages replacing doctor, physician and patient? Is this being discussed in other countries?